Request Form For Internet Image Removal per Florida Statue 28.2221(5)(b) Date:________________________ Requestor’s Name:____________________________________________________________ Phone Number: (optional)______________________________________________________ For Blocking Official Record Images Instrument Number/Book and Page Number/Document Type For Official Use Only: Date Request Received:________________________ Date Request Completed:_______________________ Clerk Processing Request:______________________ This document is used to request the removal of certain "sensitive" document types from the Clerk's publicly available website. Any "affected person" may request that images of the following types of documents be removed from a Clerk's "publicly available Internet website": Military Discharge , Death Certificates Recorded records of paper relating to matters or cases governed by : The Florida Rules of Family Law The Florida Rules of Juvenile Procedure The Florida Rules of Probate The request must be in writing and may be delivered in person, by mail, electronically, or by facsimile. The request must specify the identification page number of the document to be removed. No fee is charged for this service. Florida law requires that images and copies of the above-listed documents remain on file and available to the public upon request in the Office of the Clerk/County Recorder. Please complete and mail or fax form to: Recording Division, Lake County Clerk of Circuit Court, 122 E. Main Street, Post Office Box 7800,Tavares, FL 32778-7800 FAX: (352) 253-2600 Revised 8/25/06 American LegalNet, Inc. www.FormsWorkflow.com